Five Synchronous Melanomas: Role of Dermoscopy as a Triage Tool to Manage Melanoma During the COVID-19 Pandemic

Introduction

Multiple meta-analyses have shown that dermoscopy is more accurate than the naked eye in melanoma diagnosis [1]. Since dermoscopy has direct histopathological correlates, it can be used to triage and manage pigmented lesions [2]. Certain colors under dermoscopy such as blue over raised areas are indicators of deep melanin, whereas on flat surfaces may indicate regression [2]. Furthermore, certain structures indicate melanoma invasion such as shiny white streaks or blue-whitish veil [2]. Hence, when large lesions are challenging to be excised completely, these areas suspicious for invasion under dermoscopy such as raised blue-gray areas could be sampled in order to maximize the histologic results. Moreover, dermoscopy also allows the identification of small invasive melanomas thus improving its management. During our daily practice, currently in the middle of the COVID-19 pandemic, we face challenging cases that need to be managed with fewer visits than usual.

Case Presentation

An 89-year-old man with multiple comorbidities, ECOG 3, was referred for evaluation of a nasal pigmented lesion. Previous biopsies did not reveal malignancy but he referred enlargement over time. A brown-black 2.5 cm-patch with ill-defined borders covered patient’s central nasal dorsum (Figure 1A). Dermoscopy showed asymmetric pigment around follicles, peppering, angulated lines, and areas of follicle invasion (Figures 1, B, C and D). A complete cutaneous examination was performed identifying four further suspicious lesions. One black 2.1 × 1 cm macule on the chest (Figure 2A) showing peripheral streaks asymmetrically distributed and a central blue-whitish veil on dermoscopy (Figure 2B). One elongated brown to black 1.4 × 0.8 cm macule on the neck (Figure 2C), with an atypical pigmented network and an irregular black blotch on dermoscopy (Figure 2D). A brown to black 0.5 × 0.3 cm macule on the upper dorsum showing an atypical brown network on dermoscopy (Figures 2, E and F). Ultimately, a brown to black 0.7 × 0.6 cm macule on his right shoulder, with an atypical brown network and an inferior-left homogenous brown area on dermoscopy (Figures 2, G and H).

Figure 1.

(A) Clinical image of the nasal dorsum pigmented lesion consisting of a brown-black 2.5cm patch with ill-defined borders that covers the central nasal dorsum. (B–D) Dermoscopy images showing asymmetric pigmented follicular openings (arrows), angulated or polygonal lines (arrowheads), blue-gray dots or peppering (asterisk), and areas of follicle invasion (circles).

Figure 2.

(A) Clinical image of the 2.2 × 2 cm macule on the chest. (B) Dermoscopic image showing peripheral streaks asymmetrically distributed and central blue-whitish veil. (C) Clinical image of the pigmented lesion on the neck, which presented as an elongated brown-black macule of 1.4 × 0.8 cm. (D) Dermoscopy of the neck lesion where atypical pigmented network and an irregular black blotch at the periphery can be observed. (E) Clinical image of the upper dorsum brown to black 0.5 × 0.3 cm macule. (F) Upper dorsum lesion dermoscopy showing an atypical brown network. (G) Clinical image of the pigmented lesion on the right shoulder presented as a brown-black 0.7 × 0.6 cm macule. (H) Atypical brown network and inferior-left homogeneous brown area on dermoscopy of the shoulder lesion.

Given the number of lesions suggesting melanoma and considering the patient comorbidities, a shave-excision was performed during the same initial appointment of the smaller lesions suspected to be in situ by dermoscopy (atypical network with absence of blue-gray color, shiny white structures or vessels): the shoulder and upper dorsum lesions. The patient was scheduled for complete excision of the chest and neck lesions, due to suspicion of invasion (blue-whitish veil on dermoscopy) on the former, and due to a larger size and irregular shape on the latter. Regarding the nasal lesion, although no signs of invasion were suspected, due to its large size and the potentially complex reconstruction, a dermoscopy-targeted punch biopsy was performed on the brown area, and not on the blue-gray area which may have only revealed regression.

Results from histologic examination yielded four in situ melanomas, and an invasive melanoma with a 0.6 mm Breslow index (chest lesion). Wide local excision was later performed in all lesions according to the current guidelines. The patient is alive with no signs of active disease.

Conclusions

We present an unusual case of a man with five synchronous primary melanomas, whose management was streamlined thanks to dermoscopy. Hence, by using dermoscopy we could simplify the patient flow and minimize the number of appointments, especially useful in the current context of COVID-19 pandemic.